2135 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387)
VBATS ACCOUNT AUTHORIZATION — COUNTY / TRIBAL VETERAN SERVICE OFFICES

Wis. Stats. Chapter 45 COUNTY / TRIBAL VETERAN SERVICE OFFICE AND OFFICE ADDRESS	This is the permanent record used by the WDVA to verify the position of County / Tribal Veteran Service Office personnel authorized to utilize the Veterans Benefit Application Tracking System (VBATS). WDVA will use this form to grant or remove future VBATS access. County / Tribal officials will use it to notify WDVA of changes, additions, or removals of personnel. Check and fill in the Replacement name to remove an account.
DATE
APPLICANT #1	Name
Title
Phone ( )	Addition Replacement for:	Annual Renewal
Signature Date	Email
By signing above I acknowledge and understand that criminal and/or civil penalties and/or civil damages may apply if I obtain unauthorized access to, or make unauthorized disclosure or inspection of records obtained from the VBATS application. I further understand if I obtain unauthorized access to, or make unauthorized disclosure or inspection of records my access to the VBATS application will be permanently revoked.
APPLICANT #2	Name
Title
Phone ( )	Addition Replacement for:	Annual Renewal
Signature Date	Email
By signing above I acknowledge and understand that criminal and/or civil penalties and/or civil damages may apply if I obtain unauthorized access to, or make unauthorized disclosure or inspection of records obtained from the VBATS application. I further understand if I obtain unauthorized access to, or make unauthorized disclosure or inspection of records my access to the VBATS application will be permanently revoked.
APPLICANT #3	Name
Title
Phone ( )	Addition Replacement for:	Annual Renewal
Signature Date	Email
By signing above I acknowledge and understand that criminal and/or civil penalties and/or civil damages may apply if I obtain unauthorized access to, or make unauthorized disclosure or inspection of records obtained from the VBATS application. I further understand if I obtain unauthorized access to, or make unauthorized disclosure or inspection of records my access to the VBATS application will be permanently revoked.
COUNTY EXECUTIVE, ADMINISTRATOR, OR ADMINISTRATIVE COORDINATOR	I certify on behalf of my county / tribe that these signatures are valid and that these individuals are authorized to access and utilize the VBATS for WDVA programs and benefits. I understand that criminal and/or civil penalties and/or civil damages may apply if I, or the signatories above obtain unauthorized access to, or make an unauthorized disclosure or inspection of records obtained from the VBATS database, and agree to indemnify and hold harmless the WDVA for all costs and damages, including reasonable attorney’s fees for all such violations occurring after the date of the signing of this document.
Name
Title
Phone ( )	Addition Replacement for:	Annual Renewal
Signature Date	Email